Infections: Fever X Rash (MMR, Scarlet Fever, PV, VZV) Flashcards
A child presents with fever with a blotchy or spotty rash (macular rash).
What are your key differentials:
- Infective causes [4]
- Systemic causes [4]
Infective causes:
- Measles
- Rubella
- Erythema infectiosum (parovirus)
- Roseola infantum
Systemic causes:
- Kawasaki disease
- Erythema multiforme
- Systemic JIA (Stills)
- Allergy or drug reaction
- Scarlet fever
A patient presents with the following. What is the most likely dx? [1]
Measles xox
Describe the clinical features of measles [3]
prodrome:
- irritable, conjunctivitis, fever
Koplik spots (before rash):
- white spots (‘grain of salt’) on buccal mucosa
rash:
- starts behind ears then to whole body, discrete maculopapular rash becoming blotchy & confluent
- late symptom
Describe the course of symptoms in measles [3]
Name this feature of measles infection [1]
Koplik spots
How do you investigate for measles? [1]
Measles is generally diagnosed clinically, but PCR testing is helpful to confirm the diagnosis.
IgM antibodies can be detected within a few days of rash onset
Describe the management of measles [1]
Most cases are self-limiting within 1 week with self-care measures such as fluids and symptomatic management
notifiable disease → inform public health
What is the most common complcation [1] and common cause of death [1] due to measles?
otitis media: the most common complication
pneumonia: the most common cause of death
Describe the complications of measles [+]
Stomatitis
Otitis media
keratoconjunctivitis
corneal ulceration
diarrhoea
Bronchopneumonia
Secondary bacterial infection
Encephalitis:
- Acute form occurs after 1 week
- Subacute sclerosing panencephalitis (SSPE): after about 5 years
Describe the difference in encephalitis formed by measles encephalitis [2]
Encephalitis:
Acute form occurs after 1 week:
- 15% mortalitly, 25% sequelae
Subacute sclerosing panencephalitis (SSPE): after about 5 years:
- slowly progressive neurological decline, fatal
Describe how you differentiate between measles and scarlet fever [1]
Measles has a maculopapular rash that starts on the face and moves down the body; Koplik spots
Scarlet fever has a distinctive rash that appears 1–2 days after the onset of other symptoms, first on the neck and then spreading to the trunk and extremities; strawberry tongue
Describe how a the rash in measles spreads around the body [1]
The rash typically STARTS behind the ears and then spreads to the whole body
A child presents with a rash on both cheeks, fever and and URTI.
What is the most likely diagonsis? [1]
What causes this? [1]
Slapped cheek syndrome:
- Rash on both cheeks, fever (often hardly noticebale), upper respiratory tract infection symptoms.
- Rash rarely involves hand or feet
- Caused by parvovirus B19
Describe the characteristics of the rash in slapped cheek syndrome [3]
The rose-red rash makes the cheeks appear bright red, hence the name ‘slapped cheek syndrome’. The rash may spread to the rest of the body but unlike many other rashes, it only rarely involves the palms and soles.
The child begins to feel better as the rash appears and the rash usually peaks after a week and then fades.
some months afterwards, a warm bath, sunlight, heat or fever will trigger a recurrence of the bright red cheeks and the rash itself.
Which population group are particularly risk if they suffer from parvovirus? [2]
SCD - causes aplastic crisis
Pregnant: can cause fetal loss from hydrops fetalis
What is the most likely complication of slapped cheek syndrome? [1]
Anaemia
Explain. the complication pregnant woman are at risk of after contracting parvovirus B19? [1]
What is the treatment for pregnant women [1]
Hydrops fetalis.
* parvovirus B19 in pregnant women can cross the placenta in pregnant women
* this causes severe anaemia due to viral suppression of fetal erythropoiesis → heart failure secondary to severe anaemia → the accumulation of fluid in fetal serous cavities (e.g. ascites, pleural and pericardial effusions)
* treated with intrauterine blood transfusions
When are children with slapped cheek syndrome no longer infectious? [1]
Once the rash appears.
Deficiency of which vitamin is a risk factor for measles? [1]
Vitamin A
Roseola infantum is also known as just roseola or sixth disease. This is caused by [] and less frequently by []
Roseola infantum is also known as just roseola or sixth disease. This is caused by human herpesvirus 6 (HHV-6) and less frequently by human herpesvirus 7 (HHV-7).
Describe the pattern of Roseola infantum [5]
Roseola has a typical pattern of illness.:
- It presents 1 – 2 weeks after infection with a high fever (up to 40ºC) that comes on suddenly, lasts for 3 – 5 days and then disappears suddenly.
- There may be coryzal symptoms, sore throat and swollen lymph nodes during the illness.
- When the fever settles, the rash appears for 1 – 2 days
- The rash consists of a mild erythematous macular rash across the arms, legs, trunk and face and is not itchy.
Children make a full recovery within a week and do not generally need to be kept off nursery if they are well enough to attend.
What is the incubation period like for rubella? [1]
Symptoms start 2 weeks after exposure.
Describe the rash caused by rubella [1]
What are the other significant clinical features? [4]
Rash that starts on the face and spreads to the trunk and rest of body
Other clinical features:
* mild fever
* sore throat
* lymphadenopathy: suboccipital and postauricular
* Often associated with arthritis and arthralgia
A child is dx with rubella.
What advise should you give them about attending school? [1]
Children should stay off school for at least 5 days after the rash appears.
Children should avoid pregnant women.
Rubella poses a serious risk to unvaccinated pregnant women. Congenital rubella infection (especially in the first 20 weeks of pregnancy) can lead to congenital rubella syndrome, which can cause severe fetal abnormalities such as: [4]
What is the clinical triad? [3]
- Cataracts
- Deafness
- Patent ductus arteriosus
- Brain damage
Rubella is dangerous in pregnancy and can lead to congenital rubella syndrome, which is a triad of deafness, blindness and congenital heart disease
What are the complications of rubella infection? [2]
Complications are rare but include thrombocytopenia and encephalitis.
.
Suboccipital lymphadenopathy x rash =? [1]
Rubella !
Scarlet fever occurs typically at which ages? [1]
It is a reaction to which organism? [1]
Scarlet fever is a reaction to erythrogenic toxins produced by Group A haemolytic streptococci (usually Streptococcus pyogenes). It is more common in children aged 2 - 6 years with the peak incidence being at 4 years.
Describe the clinical features of scarlet fever [4]
- Coarse red rash on the cheeks, sore throat, headache, fever, ‘sandpaper’ texture rash
- bright red tongue / strawberry tongue
- fever for 24/48 hours
- rash appears first on torso and spares palms and soles
- Cervical lymphadenopathy
Scarlet fever is caused by an exotoxin produced by the streptococcus pyogenes (group A strep) bacteria. It is characterised by a red-pink, blotchy, macular rash with rough “sandpaper” skin that starts on the trunk and spreads outwards.
Other features:
Describe the management for scarlet fever [2]
When can children return to school? [1]
- oral penicillin V for 10 days
- patients who have a penicillin allergy should be given azithromycin
- children can return to school 24 hours after commencing antibiotics
- scarlet fever is a notifiable disease
What is the most common complication of scarlet fever ? [1]
otitis media
Name 4 complications of scarlet fever [4]
- otitis media: the most common complication
- rheumatic fever: typically occurs 20 days after infection
- acute glomerulonephritis: typically occurs 10 days after infection
- invasive complications (e.g. bacteraemia, meningitis, necrotizing fasciitis) are rare but may present acutely with life-threatening illness
Which complication of scarlet fever typically presents 10 days after infection? [1]
Glomerulonephritis
Which complication of scarlet fever typically presents 20 days after infection? [1]
Rheumatic fever
What are the three ddx for fever with vesicles? [3]
HSV
VZV
Hand, Foot and Mouth (cocksackie)
Describe the presentation of chickenpox infection [2]
- Include where the rash starts and timecourse [1]
Chickenpox is characterised by widespread, erythematous, raised, vesicular (fluid filled), blistering lesions.
- The rash usually starts on the trunk or face and spreads outwards affecting the whole body over 2 – 5 days. Eventually the lesions scab over, at which point they stop being contagious.
Other symptoms:
* Fever is often the first symptom
* Itch
* General fatigue and malaise
Describe a key skin complication of VZV infection [1]
What would be key symptoms that would make you suspect this manifestation? [1]
Bacterial infection (most commonly Strep. pyogenes) infections of lesions:
- Can cause cellulitis or even necrotising fasciitis
Would present as: Fever (from initial infection), gets better, then develops second wave of fever
Describe a CNS complication of VZV infection [1]
Describe a resp. complication of VZV infection [1]
Encephalitis - presents with dramatic cerebella ataxia
Pneumonia - presents with calcifications on CXR
A child w/ immunosuppresion becomes exposed to VZV.
How would you manage this patient? [1]
How would you treat them if they became infected? [1]
Prophylaxis zoster immunoglobulin (ZIG)
If infected: IV acylovir
A child presents with fever, malaise and tonsillitis associated with a ‘strawberry’ tongue and a fine punctate erythematous rash sparing the area around the mouth
Strep. pyogenes
A child presents with fever, malaise and tonsillitis associated with a ‘strawberry’ tongue and a fine punctate erythematous rash sparing the area around the mouth
strawberry’ tongue
A child presents with fever, conjunctivitis and being irritable. He has also developed a maculopapular rash which started behind ears before spreading and becoming blotchy & confluent - measles
Encephalitis
Child with fever, conjunctivitis, white spots on buccal mucosa, rash starting behind ears - measles
subacute sclerosing panencephalitis
Rubella
Chickenpox - exclusion from school: until lesions have crusted over
A 6-year-old girl who has sickle cell disease develops pallor and fatigue shortly after a viral illness characterised by an erythematous rash affecting her cheeks
Dx? [1]
parvovirus B19
a 5-year-old develops a fine maculopapular rash on his face which is spreading down his body. Suboccipital lymphadenopathy is noted on examination
Dx? [1]
Rubella
Slapped-cheek rash
What are the school exclusion periods for [5]:
- Slapped cheek
- Roseola
- Head lice
- Hand food and mouth
- Scarlet fever
Slapped cheek: none
Roseola: none
Head lice: none
Hand food and mouth: none
Scarlet fever: 24 hrs after commencing abx
What are the school exclusion periods for [5]:
- Whooping cough
- Measles
- Rubella
- Chickenpox
Whooping cough:
- 2 days after abx start (or 21 days of symptoms for no abx)
Measles:
- 4 days from onset of rash
Rubella:
- 5 days from onset of rash
Chickenpox:
- when all lesions have crusted over
A child is dx with mumps.
What advise should you give about school exclusion? [1]
**Exclude for 5 days from onset of swollen glands **
